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Washington Apple Health (Medicaid)
Planned Home Births & Births in Birthing Centers Billing
Guide January 1, 2017
Every effort has been made to ensure this guide’s accuracy. If
an actual or apparent conflict between this document and an agency
rule arises, the agency rules apply.
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About this guide*1 This guide takes effect January 1, 2017, and
supersedes earlier billing guides to this program. HCA is committed
to providing equal access to our services. If you need an
accommodation or require documents in another format, please call
1-800-562-3022. People who have hearing or speech disabilities,
please call 711 for relay services.
Washington Apple Health means the public health insurance
programs for eligible Washington residents. Washington Apple Health
is the name used in Washington State for Medicaid, the children's
health insurance program (CHIP), and state-only funded health care
programs. Washington Apple Health is administered by the Washington
State Health Care Authority.
What has changed?
Subject Change Reason for Change
Fee-for-service clients with other primary health insurance to
be enrolled into managed care
Added a new section regarding additional changes for some
fee-for-service clients.
Policy change
How can I get agency provider documents? To access provider
alerts, go to the agency’s provider alerts web page. To access
provider documents, go to the agency’s provider billing guides and
fee schedules web page.
*This guide is a billing instruction.
http://www.hca.wa.gov/node/316http://www.hca.wa.gov/node/301
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2
Copyright disclosure
Current Procedural Terminology (CPT) copyright 2016 American
Medical Association (AMA). All rights reserved. CPT is a registered
trademark of the AMA. Fee schedules, relative value units,
conversion factors and/or related components are not assigned by
the AMA, are not part of CPT, and the AMA is not recommending their
use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data
contained or not contained herein.
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Table of Contents About this guide*
.................................................................................................................1
What has changed?
..............................................................................................................1
How can I get agency provider documents?
........................................................................1
Resources Available
.................................................................................................................6
Definitions
.................................................................................................................................7
Program Overview
...................................................................................................................9
What does the Planned Home Births and Births in Birthing Centers
program
provide?....................................................................................................................9
When does the agency cover Planned Home Births and Births in
Birthing
Centers?....................................................................................................................9
What are the requirements to be an agency-approved planned home
birth provider or birthing center provider?
...................................................................................10
What equipment, supplies, and medications are recommended or
required for a planned home birth?
...............................................................................................12
Client Eligibility
.....................................................................................................................13
How can I verify a patient’s eligibility?
............................................................................13
Are clients enrolled in an agency-contracted managed care
organization eligible? ..........14
First Steps Program Services
.......................................................................................14
Maternity Support Services (MSS)/Infant Case Management (ICM)
.........................15 Childbirth Education
....................................................................................................15
Effective January 1, 2017, some fee-for-service clients who have
other primary health insurance will be enrolled into managed care
.............................................16
Effective April 1, 2016, important changes to Apple Health
............................................16 New MCO enrollment
policy – earlier enrollment
......................................................16 How does
this policy affect providers?
........................................................................17
Behavioral Health Organization (BHO)
......................................................................17
Fully Integrated Managed Care (FIMC)
......................................................................17
Apple Health Core Connections
(AHCC)....................................................................18
AHCC complex mental health and substance use disorder services
...........................18 Contact Information for Southwest
Washington
.........................................................19
Prenatal Management and Risk Screening Guidelines
......................................................20 What are
the risk screening criteria?
..................................................................................20
Risk screening
criteria..................................................................................................20
Smoking Cessation for Pregnant Women
..........................................................................21
Prenatal Management/Consultation & Referral
.................................................................21
Prenatal indications for consultation and referral
..............................................................23
Intrapartum
.........................................................................................................................24
Postpartum
.........................................................................................................................25
Newborn
.............................................................................................................................26
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Authorization..........................................................................................................................27
What is the expedited prior authorization (EPA) process?
................................................27 When do I need
to create an EPA number?
.......................................................................27
How do I create an EPA
number?......................................................................................27
EPA criteria for drugs not billable by licensed midwives
.................................................27
Coverage
Table.......................................................................................................................29
Routine Prenatal Care
..................................................................................................29
Additional monitoring
..................................................................................................30
Delivery (intrapartum)
.................................................................................................30
Postpartum
...................................................................................................................30
Labor
management.......................................................................................................31
Other Codes
.................................................................................................................32
Facility Fee
Payment....................................................................................................35
Home Birth Kit
............................................................................................................35
What fees do I bill the agency?
..........................................................................................35
What does global (total) obstetrical care include?
.............................................................36
What does routine prenatal care include?
..........................................................................36
When an eligible client receives services from more than one
provider, the agency reimburses each provider for the services
furnished .................................37
Is obstetrical care allowed to be unbundled?
.....................................................................37
When a client transfers to your practice late in the pregnancy
....................................38 If the client moves to
another provider (not associated with your practice),
moves out of your area prior to delivery, or loses the pregnancy
..........................38 If the client changes insurance during
pregnancy
........................................................38
Coding for prenatal care only
............................................................................................38
Coding for
deliveries..........................................................................................................39
Natural Deliveries
..............................................................................................................39
Coding for postpartum care only
.......................................................................................40
Additional monitoring for high-risk conditions
.................................................................40
Labor
management.............................................................................................................42
Does the agency pay for newborn screening tests?
...........................................................43 How
is the administration of immunizations billed?
.........................................................43 How are
home-birth supplies billed?
.................................................................................44
Are medications billed separately?
....................................................................................44
Long Acting Reversible Contraception (LARC)
...............................................................44
How are newborn assessments billed?
...............................................................................44
Home birth
setting........................................................................................................44
Birthing center births
...................................................................................................45
How is the facility fee billed in birthing centers?
..............................................................45
What additional documentation must be kept in the client’s record?
................................46
Prenatal care records
....................................................................................................46
Intrapartum/postpartum care records
...........................................................................46
Informed consent materials
..........................................................................................46
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Billing
......................................................................................................................................48
What are the general billing requirements?
.......................................................................48
Billing with expedited prior authorization (EPA)
..............................................................48
Can more than one EPA number be submitted on the same claim?
............................48 How do I bill claims electronically?
..................................................................................48
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Resources Available
Topic Contact
Policy questions or exception to rule questions
Planned Home Births and Births in Birthing Centers Program
Manager Health Care Authority Program Mgmt & Authorization
Section PO Box 45506 Olympia, WA 98504-5506 FAX 360-725-1966
Newborn screenings Department of Health 206-361-2890 or
866-660-9050 Email: [email protected]
Medical information University of Washington Med Consultation
Line 800-326-5300 (toll free)
Maternity Support Services/Infant Case Management
See First Steps web page Email: [email protected] Phone:
360-725-1293
Which birthing centers are agency-approved birthing centers?
• Bellingham Birthing Center - Bellingham, WA • Birthing Inn -
Tacoma, WA • Birthright LLC - Spokane, WA • Birthroot Midwives
& Birthing Center - Bellingham, WA • Cascade Birth Center -
Everett, WA • Center for Birth LLC - Seattle, WA • Eastside Birth
Center - Bellevue, WA • Greenbank Women’s Clinic and Childbirth
Center-
Greenbank, WA • Lakeside Birth Center - Sumner, WA • Mount
Vernon Birth Center - Mount Vernon, WA • Puget Sound Birth Center -
Kirkland, WA • Salmonberry Community Birthing Center – Poulsbo, WA
• Seattle Home Maternity Services and Childbirth Center-
Seattle, WA • Sprout Birthing Center - Mountlake Terrace, WA •
The Birth House - Olympia, WA • Wenatchee Midwife and Childbirth
Center - Wenatchee
mailto:[email protected]://www.hca.wa.gov/node/796mailto:[email protected]
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Definitions This section defines terms and abbreviations,
including acronyms, used in this billing guide. Refer to Chapter
182-500 WAC for a complete list of definitions for Washington Apple
Health. Birthing Center – A specialized facility licensed as a
childbirth center by the Department of Health (DOH) (WAC
246-329-010) Birthing Center Provider – Any of the following
individuals who have a Core Provider Agreement with the agency to
deliver babies in a birthing center: • A midwife currently licensed
in the State
of Washington under chapter 18.50 RCW
• Nurse Midwife currently licensed in the State of Washington
under chapter 18.79 RCW
• Physician licensed in the State of Washington under chapters
18.57 or 18.71 RCW
Bundled services – Services integral to the major procedure that
are included in the fee for the major procedure. For the Planned
Home Birth and Births in Birthing Centers program, certain services
which are customarily bundled must be billed separately (unbundled)
when the services are provided by different providers. Chart - A
compilation of medical records on an individual patient.
Consultation – The process whereby the provider, who maintains
primary management responsibility for the client’s care, seeks the
advice or opinion of a physician (MD/DO) on clinical issues that
are patient-specific. These discussions may
occur in person, by electronic communication, or by telephone. A
consulting relationship may result in: • Telephone, written or
electronic mail
recommendations by the consulting physician.
• Co-management of the patient by the birthing center provider
and the consulting physician.
• Referral of the patient to the consulting physician for
examination and/or treatment.
• Transfer of patient’s care from the birthing center or home
birth provider to the consulting physician.
Facility fee – The portion of the agency’s payment for the
hospital or birthing center charges. This does not include the
agency’s payment for the professional fee. Global fee – The fee the
agency pays for total obstetrical care. Total obstetrical care
includes all bundled prenatal care, delivery services, and
postpartum care. High-risk pregnancy – Any pregnancy that poses a
significant risk of a poor birth outcome. Home birth kit – A kit
contains that disposable supplies that are used in a planned home
birth (see list of recommended or required supplies).
http://app.leg.wa.gov/wac/default.aspx?cite=182-500http://apps.leg.wa.gov/wac/default.aspx?cite=246-329-010http://apps.leg.wa.gov/wac/default.aspx?cite=246-329-010http://apps.leg.wa.gov/rcw/default.aspx?cite=18.50http://apps.leg.wa.gov/rcw/default.aspx?cite=18.50http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79http://apps.leg.wa.gov/rcw/default.aspx?cite=18.57http://apps.leg.wa.gov/rcw/default.aspx?cite=18.71
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Home Birth Provider - • A midwife currently licensed in the
State of
Washington under chapter 18.50 RCW • A nurse-midwife currently
licensed in the
State of Washington under chapter 18.79 RCW
• A physician licensed in the State of Washington under chapters
18.57 or 18.71 RCW who has qualified to become a home birth
provider who will deliver babies in a home setting, and has signed
a core provider agreement with the Health Care Authority
Midwife – An individual possessing a valid, current license to
practice midwifery in the State of Washington as provided in
chapter 18.50 RCW, or an individual recognized by the Washington
Nursing Care Quality Assurance Commission as a certified nurse
midwife as provided in chapter 18.79 RCW and chapter 246-834 WAC.
Planned home birth – A natural birth that takes place in a home
setting and is assisted by a qualified licensed midwife, certified
nurse midwife who is licensed as an ARNP, or a physician.
Professional Fee – The portion of the agency’s payment for services
that rely on the provider’s professional skill, or training, or the
part of the reimbursement that recognizes the provider’s cognitive
skill. Record – Dated reports supporting claims for medical
services provided in an office, nursing facility, hospital,
outpatient, emergency room, or other place of service.
http://apps.leg.wa.gov/rcw/default.aspx?cite=18.50http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79http://apps.leg.wa.gov/rcw/default.aspx?cite=18.57http://apps.leg.wa.gov/rcw/default.aspx?cite=18.71http://apps.leg.wa.gov/rcw/default.aspx?cite=18.50http://apps.leg.wa.gov/rcw/default.aspx?cite=18.50http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79http://apps.leg.wa.gov/wac/default.aspx?cite=246-834
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Program Overview
What does the Planned Home Births and Births in Birthing Centers
program provide? The Planned Home Births and Births in Birthing
Centers program provides a safe alternative delivery setting to
pregnant agency clients who are at low-risk for adverse birth
outcomes. These services promote access to care by allowing
low-risk clients to give birth in an out-of-hospital setting.
When does the agency cover Planned Home Births and Births in
Birthing Centers? (WAC 182-533-0600(1)) The agency covers planned
home births and births in birthing centers for its clients when the
client and the maternity care provider choose to have a home birth
or to give birth in an agency-approved birthing center and the
client: • Is eligible for categorically needy (CN) or medically
needy (MN) scope of care (see
Client Eligibility). • Has an agency-approved home birth
provider who has accepted responsibility for the
planned home birth or a provider who has accepted responsibility
for a birth in an agency-approved birthing center.
• Is expected to deliver the child vaginally and without
complication (i.e., with a low risk
of adverse birth outcome). • Passes agency’s risk screening
criteria. (For risk screening criteria, see Prenatal
Management/Risk Screening Guidelines). What are the requirements
to be an agency-approved birthing center facility? (WAC
182-533-0600(3)) An agency-approved birthing center facility must:
• Be licensed as a childbirth center by the Department of Health
(DOH) as defined in
chapter 246-329-010 WAC.
http://apps.leg.wa.gov/wac/default.aspx?cite=182-533-0600http://apps.leg.wa.gov/wac/default.aspx?cite=182-533-0600http://apps.leg.wa.gov/wac/default.aspx?cite=246-329-010
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• Be specifically approved by the agency to provide birthing
center services (see Resources Available for a list of approved
centers).
• Have a valid core provider agreement (CPA) with the agency. •
Maintain standards of care required by DOH for licensure.
What are the requirements to be an agency-approved planned home
birth provider or birthing center provider? (WAC
182-533-0600(2),(5), and (6)) Agency-approved planned home birth
providers and birthing center providers must: • Have a core
provider agreement (CPA) with the agency. • Be licensed in the
State of Washington as a:
Midwife under chapter 18.50 RCW Nurse midwife under chapter
18.79 RCW Physician under chapters 18.57 or 18.71 RCW
• Have evidence of current cardiopulmonary resuscitation (CPR)
training for:
Adult CPR Neonatal resuscitation
• Have current, written and appropriate plans for consultation,
emergency transfer, and
transport of client and/or newborn to a hospital.
• Obtain from the client a signed informed consent form,
including the criteria listed in Authorization, in advance of the
birth.
• Follow the agency’s Risk Screening Guidelines (see Prenatal
Management/Risk
Screening Guidelines) and consult with or refer the client or
newborn to a physician or hospital when medically appropriate.
• Make appropriate referral of the newborn for pediatric care
and medically necessary
follow-up care.
http://apps.leg.wa.gov/wac/default.aspx?cite=182-533-0600http://apps.leg.wa.gov/rcw/default.aspx?cite=18.50http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79http://apps.leg.wa.gov/rcw/default.aspx?cite=18.57http://apps.leg.wa.gov/rcw/default.aspx?cite=18.71
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• Inform parents of the benefits of a newborn screening test and
offer to send the newborn’s blood sample to DOH for testing (the
parent may refuse this service). DOH will bill the agency for
payments of HCPCS code S3620.
In addition, agency-approved home birth providers must send the
following documentation to the Planned Home Birth and Birthing
Center Program Manager (see Resources Available): • A certificate
of current license as midwife or licensed nurse midwife.
• The names and national provider identifier (NPI) number of
back up midwives that are
current Washington Apple Health providers and will provide 24
hour-per-day coverage. • Documentation of local area emergency
medical services and emergency response
capability in the area.
• Professional consultation plan and referral.
• A copy of the midwife’s informed consent that includes newborn
screening, prophylactic eye ointment, and vitamin K injection.
• Documentation of participation in a formal, state sanctioned,
quality
assurance/improvement program or professional liability review
process (e.g., programs offered by Joint Underwriting Association
(JUA), Midwives’ Association of Washington State).
• Copy of the of the midwife’s and/or birthing center’s
professional liability policy.
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What equipment, supplies, and medications are recommended or
required for a planned home birth? Nondisposable equipment: Adult
mask and oral airway Fetoscope and/or Doppler device (with extra
batteries if only Doppler) Oxygen tank with tubing and flow meter
Neonatal resuscitation mask and bag Portable light source Portable
oral suction device for infant Sterile birth instruments Sterile
instruments for episiotomy and repair Stethoscope and
sphygmomanometer Tape measure Thermometer Timepiece with second
hand O2 saturation monitor Medications available: Pitocin, 10 U/ml
Methergine, 0.2 mg/ml Epinephrine, 1:1000 MgSO4, 50% solution,
minimum 2-each of 5gms in 10 cc vials Local anesthetic for perineal
repair Vitamin K, neonatal dosage (1 mg/0.5 ml) IV fluids, one or
more liters of LR Recommended home-birth-kit supplies: IV set-up
supplies Venipuncture supplies Urinalysis supplies - clean catch
cups and dipsticks Injection supplies suitable for maternal
needs
Injection supplies suitable for neonatal needs Clean gloves
Sterile gloves: pairs and/or singles in appropriate size Sterile
urinary catheters Sterile infant bulb syringe Sterile cord clamps,
binding equipment or umbilical tape Antimicrobial solution(s) for
cleaning exam room and client bathroom Antimicrobial
solution(s)/brush for hand cleaning Sterile amniohooks or similar
devices Cord blood collection supplies Appropriate device for
measuring newborn’s blood sugar values Suture supplies Sharps
disposal container, and means of storage and disposal of sharps
Means of disposal of placenta Required home-birth-kit supplies:
Neonatal ophthalmic ointment (or other approved eye
prophylaxis)
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Client Eligibility
How can I verify a patient’s eligibility? Providers must verify
that a patient has Washington Apple Health coverage for the date of
service, and that the client’s benefit package covers the
applicable service. This helps prevent delivering a service the
agency will not pay for. Verifying eligibility is a two-step
process: Step 1. Verify the patient’s eligibility for Washington
Apple Health. For detailed
instructions on verifying a patient’s eligibility for Washington
Apple Health, see the Client Eligibility, Benefit Packages, and
Coverage Limits section in the agency’s current ProviderOne Billing
and Resource Guide. If the patient is eligible for Washington Apple
Health, proceed to Step 2. If the patient is not eligible, see the
note box below.
Step 2. Verify service coverage under the Washington Apple
Health client’s benefit
package. To determine if the requested service is a covered
benefit under the Washington Apple Health client’s benefit package,
see the agency’s Program Benefit Packages and Scope of Services web
page.
Note: Patients who are not Washington Apple Health clients may
submit an application for health care coverage in one of the
following ways: 1. By visiting the Washington Healthplanfinder’s
website at:
www.wahealthplanfinder.org. 2. By calling the Customer Support
Center toll-free at: 855-WAFINDER
(855-923-4633) or 855-627-9604 (TTY). 3. By mailing the
application to:
Washington Healthplanfinder PO Box 946 Olympia, WA 98507
In-person application assistance is also available. To get
information about in-person application assistance available in
their area, people may visit www.wahealthplanfinder.org or call the
Customer Support Center.
http://www.hca.wa.gov/node/311http://www.hca.wa.gov/node/2391http://www.hca.wa.gov/node/2391http://www.wahealthplanfinder.org/http://www.wahealthplanfinder.org/
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Are clients enrolled in an agency-contracted managed care
organization eligible? (WAC 182-533-0400(2)) Yes. When verifying
eligibility using ProviderOne, if the client is enrolled in an
agency-contracted managed care organization (MCO), managed care
enrollment will be displayed on the client benefit inquiry screen
in ProviderOne. All services must be requested directly through the
client’s Primary Care Provider (PCP), except in the area of women’s
health care services. For certain services, such as maternity and
gynecological care, clients may go directly to a specialist in
women’s health without a referral from the client’s PCP. However,
the provider must be within the client’s MCO’s provider network.
The client must obtain all medical services covered under an
agency-contracted MCO through designated facilities or providers.
The MCO is responsible for: • Payment of covered services • Payment
of services referred by a provider participating with the MCO to an
outside
provider Contact the agency-contracted MCO and the PCP for
additional information on providers, including participating
hospitals and birthing facilities. Clients can contact their MCO by
calling the telephone number provided to them. If the client’s
obstetrical provider is not contracted with the client’s
agency-contracted MCO, the provider will not be paid for services
unless a referral is obtained from the MCO. For assistance or
questions, the client can call the phone number provided by the
MCO.
Note: To prevent billing denials, check the client’s eligibility
prior to scheduling services and at the time of the service and
make sure proper authorization or referral is obtained from the
agency-contracted MCO. See the agency’s ProviderOne Billing and
Resource Guide for instructions on how to verify a client’s
eligibility.
First Steps Program Services The First Steps program helps
low-income pregnant clients get the health and social services they
may need. These services help healthy mothers have healthy babies
and are available as soon as a client knows the client is pregnant.
First Steps services are supplemental services that include
Maternity Support Services (MSS), Childbirth Education, and Infant
Case Management (ICM). Eligible pregnant clients may receive
Maternity Support Services (MSS) during pregnancy and through the
post pregnancy period (the last day of the month from the 60th day
after the pregnancy ends).
http://apps.leg.wa.gov/wac/default.aspx?cite=182-533-0400http://www.hca.wa.gov/node/311http://www.hca.wa.gov/node/311
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Maternity Support Services (MSS)/Infant Case Management (ICM)
Maternity Support Services (MSS) are preventive health services for
clients to have healthy pregnancies. Services include an
assessment, education, intervention, and counseling. A team of
community health nurses, nutritionists, behavioral health
specialists and, in some agencies, community health workers,
provide the services. The intent is to provide MSS as soon as
possible in order to promote positive birth and parenting outcomes.
Pregnant clients with First Steps coverage can receive MSS during
pregnancy and through the end of the second month following the end
of the pregnancy. MSS can begin during the prenatal, delivery, or
postpartum period. Sometimes there are situations that may place
infants at a higher risk of having problems. Infant Case Management
(ICM) starts after the mother’s MSS eligibility period ends
(generally in the baby’s third month). ICM can help a client’s
family learn to use the resources in the community so that the baby
and family can thrive. ICM may start at any time during the child’s
first year. It will continue through the month of the infant’s
first birthday. For further information on the MSS/ICM program,
visit the First Steps web page and see the agency’s MSS/ICM Billing
Guide. Childbirth Education Childbirth education classes are
available to all Medicaid eligible clients. Instruction takes place
in a group setting and may be completed over several sessions.
Childbirth education is intended to help the client and the
client’s support person to understand the changes the client is
experiencing, what to anticipate prior to and during labor and
delivery, and to help develop positive parenting skills. For
further information on Childbirth Education, visit the First Steps
web page. Also, see the agency’s Childbirth Education Billing
Guide. For more information about First Steps services or to
receive a list of contracted providers, contact the First Steps
Program Manager at 360-725-1293 or the visit the First Steps web
page.
http://www.hca.wa.gov/node/796https://www.hca.wa.gov/billers-providers/claims-and-billing/professional-rates-and-billing-guides#collapse_33_accordionhttps://www.hca.wa.gov/billers-providers/claims-and-billing/professional-rates-and-billing-guides#collapse_10_accordionhttp://www.hca.wa.gov/node/796
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Effective January 1, 2017, some fee-for-service clients who have
other primary health insurance will be enrolled into managed care
On January 1, 2017, the agency enrolled some fee-for-service Apple
Health clients who have other primary health insurance into an
agency-contracted managed care organization (MCO). This change did
not affect all fee-for-service Apple Health clients who have other
primary health insurance. The agency continues to cover some
clients under the fee-for-service Apple Health program, such as
dual-eligible clients whose primary insurance is Medicare. For
additional information, see the agency’s Managed Care web site,
under Providers and Billers.
Effective April 1, 2016, important changes to Apple Health These
changes are important to all providers because they may affect who
will pay for services. Providers serving any Apple Health client
should always check eligibility and confirm plan enrollment by
asking to see the client’s Services Card and/or using the
ProviderOne Managed Care Benefit Information Inquiry functionality
(HIPAA transaction 270). The response (HIPAA transaction 271) will
provide the current managed care organization (MCO),
fee-for-service, and Behavioral Health Organization (BHO)
information. See the Southwest Washington Provider Fact Sheet on
the agency’s Regional Resources web page. New MCO enrollment policy
– earlier enrollment Beginning April 1, 2016, Washington Apple
Health (Medicaid) implemented a new managed care enrollment policy
placing clients into an agency-contracted MCO the same month they
are determined eligible for managed care as a new or renewing
client. This policy eliminates a person being placed temporarily in
fee-for-service while they are waiting to be enrolled in an MCO or
reconnected with a prior MCO. New clients are those initially
applying for benefits or those with changes in their existing
eligibility program that consequently make them eligible for Apple
Health Managed Care. Renewing clients are those who have been
enrolled with an MCO but have had a break in enrollment and have
subsequently renewed their eligibility.
http://www.hca.wa.gov/billers-providers/programs-and-services/managed-carehttp://www.hca.wa.gov/node/3111
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Clients currently in fee-for-service or currently enrolled in an
MCO are not affected by this change. Clients in fee-for-service who
have a change in the program they are eligible for may be enrolled
into Apple Health Managed Care depending on the program. In those
cases, this enrollment policy will apply.
How does this policy affect providers? • Providers must check
eligibility and know when a client is enrolled and with which
MCO.
For help with enrolling, clients can refer to the Washington
Healthplanfinder’s Get Help Enrolling page.
• MCOs have retroactive authorization and notification policies
in place. The provider must
know the MCO’s requirements and be compliant with the MCO’s new
policies. Behavioral Health Organization (BHO) The Department of
Social and Health Services (DSHS) manages the contracts for
behavioral health (mental health and substance use disorder (SUD))
services for nine of the Regional Service Areas (RSA) in the state,
excluding Clark and Skamania counties in the Southwest Washington
(SW WA) Region. BHOs will replace the Regional Support Networks
(RSNs). Inpatient mental health services continue to be provided as
described in the inpatient section of the Mental Health Services
Billing Guide. BHOs use the Access to Care Standards (ACS) for
mental health conditions and American Society of Addiction Medicine
(ASAM) criteria for SUD conditions to determine client’s
appropriateness for this level of care. Fully Integrated Managed
Care (FIMC) Clark and Skamania Counties, also known as SW WA
region, is the first region in Washington State to implement the
FIMC system. This means that physical health services, all levels
of mental health services, and drug and alcohol treatment are
coordinated through one managed care plan. Neither the RSN nor the
BHO will provide behavioral health services in these counties.
Clients must choose to enroll in either Community Health Plan of
Washington (CHPW) or Molina Healthcare of Washington (MHW). If they
do not choose, they are auto-enrolled into one of the two plans.
Each plan is responsible for providing integrated services that
include inpatient and outpatient behavioral health services,
including all SUD services, inpatient mental health and all levels
of outpatient mental health services, as well as providing its own
provider credentialing, prior authorization requirements and
billing requirements. Beacon Health Options provides mental health
crisis services to the entire population in Southwest Washington.
This includes inpatient mental health services that fall under the
Involuntary Treatment Act for individuals who are not eligible for
or enrolled in Medicaid, and short-term substance use disorder
(SUD) crisis services in the SW WA region. Within their
http://www.wahbexchange.org/new-customers/application-support/customer-support-network/http://www.wahbexchange.org/new-customers/application-support/customer-support-network/https://www.hca.wa.gov/billers-providers/claims-and-billing/professional-rates-and-billing-guides#collapse_35_accordionhttps://www.dshs.wa.gov/bha/division-behavioral-health-and-recovery/access-care-standards-acs-and-icd-informationhttp://www.asam.org/quality-practice/guidelines-and-consensus-documents/the-asam-criteria/about
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available funding, Beacon has the discretion to provide
outpatient or voluntary inpatient mental health services for
individuals who are not eligible for Medicaid. Beacon Health
Options is also responsible for managing voluntary psychiatric
inpatient hospital admissions for non-Medicaid clients. In the SW
WA region some clients are not enrolled in CHPW or Molina for FIMC,
but will remain in Apple Health fee-for-service managed by the
agency. These clients include: • Dual eligible – Medicare/Medicaid
• American Indian/Alaska Native (AI/AN) • Medically needy • Clients
who have met their spenddown • Noncitizen pregnant women •
Individuals in Institutions for Mental Diseases (IMD) • Long-term
care residents who are currently in fee-for-service • Clients who
have coverage with another carrier Since there is no BHO (RSN) in
these counties, Medicaid fee-for-service clients receive complex
behavioral health services through the Behavioral Health Services
Only (BHSO) program managed by MHW and CHPW in SW WA region. These
clients choose from CHPW or MHW for behavioral health services
offered with the BHSO or will be auto-enrolled into one of the two
plans. A BHSO fact sheet is available online. Apple Health Core
Connections (AHCC) Coordinated Care of Washington (CCW) will
provide all physical health care (medical) benefits,
lower-intensity outpatient mental health benefits, and care
coordination for all Washington State foster care enrollees. These
clients include: • Children and youth under the age of 21 who are
in foster care • Children and youth under the age of 21 who are
receiving adoption support • Young adults age 18 to 26 years old
who age out of foster care on or after their 18th
birthday American Indian/Alaska Native (AI/AN) children will not
be auto-enrolled, but may opt into CCW. All other eligible clients
will be auto-enrolled.
AHCC complex mental health and substance use disorder services
AHCC clients who live in Skamania or Clark County receive complex
behavioral health benefits through the Behavioral Health Services
Only (BHSO) program in the SW WA region. These clients will choose
between CHPW or MHW for behavioral health services, or they will be
auto-enrolled into one of the two plans. CHPW and MHW will use the
BHO Access to Care Standards
http://www.hca.wa.gov/assets/BHSO_fact_sheet.pdf
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to support determining appropriate level of care, and whether
the services should be provided by the BHSO program or CCW. AHCC
clients who live outside Skamania or Clark County will receive
complex mental health and substance use disorder services from the
BHO and managed by DSHS.
Contact Information for Southwest Washington Beginning on April
1, 2016, there will not be an RSN/BHO in Clark and Skamania
counties. Providers and clients must call the agency-contracted MCO
for questions, or call Beacon Health Options for questions related
to an individual who is not eligible for or enrolled in Medicaid.
If a provider does not know which MCO a client is enrolled in, this
information can located by looking up the patient assignment in
ProviderOne. To contact Molina, Community Health Plan of
Washington, or Beacon Health Options, please call:
Molina Healthcare of Washington, Inc. 1-800-869-7165
Community Health Plan of Washington 1-866-418-1009
Beacon Health Options Beacon Health Options
1-855-228-6502
http://www.molinahealthcare.com/members/wa/en-us/Pages/home.aspxhttp://www.molinahealthcare.com/members/wa/en-us/Pages/home.aspxhttp://www.chpw.org/http://www.chpw.org/https://www.beaconhealthoptions.com/
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Prenatal Management and Risk Screening Guidelines
What are the risk screening criteria? (WAC 182-533-0600(1)(d))
Providers must screen their clients for high-risk factors. • The
provider must consult with consulting physicians when appropriate.
Follow the
agency's Risk Screening Criteria and Indications for
Consultation and Referral on the following pages.
To be reimbursed for CPT codes 99211 through 99215 with HCPCS
modifier TH (Increased Monitoring Prenatal Management), the
client’s record must contain the appropriate ICD diagnosis code.
See the agency’s Program Policy Approved Diagnosis Codes for
Planned Home Births and Birthing Centers. Risk screening criteria
(WAC 182-533-0600(7)) The following conditions are high-risk
factors. The agency does not approve or cover planned home births
or births in birthing centers for women with a history of or
identified with any of these factors. • Previous cesarean section •
Current alcohol and/or drug addiction or abuse • Significant
hematological disorders/coagulopathies • History of deep venous
thrombosis or pulmonary embolism • Cardiovascular disease causing
functional impairment • Chronic hypertension • Significant
endocrine disorders including pre-existing diabetes (type I or type
II) • Hepatic disorders including uncontrolled intrahepatic
cholestasis of pregnancy and/or
abnormal liver function tests • Isoimmunization, including
evidence of Rh sensitization/platelet sensitization • Neurologic
disorders or active seizure disorders • Pulmonary disease
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• Renal disease • Collagen-vascular diseases • Current severe
psychiatric illness • Cancer affecting site of delivery • Known
multiple gestation • Known breech presentation in labor with
delivery not imminent • Other significant deviations from normal as
assessed by the provider
Smoking Cessation for Pregnant Women (WAC 182-533-0400(20)) For
information about smoking cessation, see Behavior change
intervention – smoking cessation in the Physician-Related
Services/Health Care Professional Services Billing Guide.
Prenatal Management/Consultation & Referral The definitions
below apply to the following tables labeled Prenatal indications
for consultation and referral. Consultation - The process whereby
the provider, who maintains primary management responsibility for
the client’s care, seeks the advice or opinion of a physician on
clinical issues that are patient-specific. These discussions may
occur in person, by electronic communication, or by telephone. A
consulting relationship may result in: • Telephonic, written, or
electronic mail recommendations by the MD/DO. • Co-management of
the patient by both the midwife and the MD/DO. • Referral of the
patient to the MD/DO for examination and/or treatment. • Transfer
of care of the patient from the midwife to the MD/DO. Referral -
The process by which the provider directs the client to a physician
(MD/DO) for management (examination or treatment) of a particular
problem or aspect of the client’s care. Transfer of care – The
process by which the provider directs the client to a physician for
complete management of the client’s care. The client must meet the
agency’s risk screening criteria in order to be covered for a
planned home birth or a birth in a birthing center.
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Note: Providers are expected to screen out high-risk pregnancy
by following the agency’s risk screening guidelines. The conditions
in the following Indications for consultation and referral prenatal
table may require either a consultation or referral. Providers
should use professional judgment in assessing and determining
appropriate consultation or referral in case of an adverse
situation. If a physician is the provider, he or she should consult
with another physician as needed. Referrals to ARNPs are
appropriate for treatment of simple infections.
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Prenatal indications for consultation and referral (Refers to
the mother’s care prior to the onset of labor)
Conditions Requiring Consultation
The agency requires physician (MD/DO) consultation and the
client MAY require referral to a physician when the following
conditions arise during the current pregnancy. • Breech at 37 weeks
• Polyhydramnios/Oligohydramnios • Significant vaginal bleeding •
Persistent nausea and vomiting causing a weight loss of > 15
lbs. • Post-dates pregnancy ( > 42 completed weeks) • Fetal
demise after twelve completed weeks gestation • Significant
size/dates discrepancies • Abnormal fetal NST(non stress test) •
Abnormal ultrasound findings • Acute pyelonephritis • Infections,
whose treatment is beyond the scope of the provider • Evidence of
large uterine fibroid that may obstruct delivery or significant
structural
uterine abnormality • No prenatal care prior to the third
trimester • Other significant deviations from normal, as assessed
by the provider
Conditions Requiring Referral
The agency requires physician (MD/DO) consultation and referral
when the following conditions arise during current pregnancy. •
Evidence of pregnancy induced hypertension (BP > 140/90 for more
than six hours
with client at rest) • Hydatidiform mole (molar pregnancy) •
Gestational diabetes not controlled by diet • Severe anemia
unresponsive to treatment (Hgb < 10, Hct
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Intrapartum (Refers to the mother’s care any time after the
onset of labor, up to and including the delivery of the
placenta)
Conditions Requiring Consultation
The agency requires physician consultation and the client MAY
require referral to a physician and/or hospital when the following
maternal conditions arise intrapartum. • Prolonged rupture of
membranes (>24 hours and not in active labor) • Other
significant deviations from normal as assessed by the provider
Conditions Requiring Referral
The agency requires physician consultation and referral to a
physician or hospital when emergency conditions in the following
list arise intrapartum. In some intrapartum situations, due to
urgency, it may not be prudent to pause medical treatment long
enough to seek physician consultation or initiate transport. •
Labor before the completion of 37 weeks gestation, with known dates
• Abnormal presentation or lie at time of delivery, including
breech • Maternal desire for pain medication, consultation or
referral • *Persistent non-reassuring fetal heart rate • Active
genital herpes at the onset of labor • Thick meconium stained fluid
with delivery not imminent • *Prolapse of the umbilical cord •
Sustained maternal fever • *Maternal seizure • Abnormal bleeding
(*hemorrhage requires emergent transfer) • Hypertension with or
without additional signs or symptoms of pre-eclampsia • Prolonged
failure to progress in active labor • *Sustained maternal vital
sign instability and/or shock
* These conditions require emergency transport.
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Postpartum (Refers to the mother’s care in the first 24 hours
following the delivery of the placenta)
Conditions Requiring Consultation
The agency requires physician consultation and the client MAY
require referral to a physician when the following maternal
conditions arise postpartum. • Development of any of the applicable
conditions listed under Prenatal or Intrapartum • Significant
maternal confusion or disorientation • Other significant deviations
from normal as assessed by the provider
Conditions Requiring Referral
The agency requires physician consultation and referral when the
following conditions arise postpartum. • *Anaphylaxis or shock •
Undelivered adhered or retained placenta with or without bleeding •
*Significant hemorrhage not responsive to treatment • *Maternal
seizure • Lacerations, if repair is beyond provider’s level of
expertise (3rd or 4th degree) • *Sustained maternal vital sign
instability and/or shock • Development of maternal fever,
signs/symptoms of infection or sepsis • *Acute respiratory distress
• *Uterine prolapse or inversion
* These conditions require emergency transport.
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Newborn (Refers to the infant’s care during the first 24 hours
following birth)
Conditions Requiring Consultation
The agency requires a pediatric physician be consulted. The
client MAY require a referral to an appropriate pediatric physician
when the following conditions arise in a neonate. • Apgar score
< 6 at five minutes of age • Birth weight < 2500 grams •
Abnormal jaundice • Other significant deviations from normal as
assessed by the provider
Conditions Requiring Referral
The agency requires that a pediatric physician be consulted and
a referral made when the following conditions arise in a neonate. •
Birth weight < 2000 grams • *Persistent respiratory distress •
*Persistent cardiac abnormalities or irregularities • *Persistent
central cyanosis or pallor • Prolonged temperature instability when
intervention has failed • *Prolonged glycemic instability •
*Neonatal seizure • Clinical evidence of prematurity (gestational
age < 35 weeks) • Loss of > 10% of birth weight /failure to
thrive • Birth injury requiring medical attention • Major apparent
congenital anomalies • Jaundice prior to 24 hours
* These conditions require emergency transport.
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Authorization
What is the expedited prior authorization (EPA) process? The
agency’s EPA process is designed to eliminate the need to request
authorization. The intent is to establish authorization criteria
and identify these criteria with specific codes, enabling providers
to create an EPA number when appropriate.
When do I need to create an EPA number? You need to create an
EPA number when administering drugs that are listed as “Not
billable by a Licensed Midwife” in the fee schedule. For licensed
midwives to be reimbursed by the agency for the administration of
these drugs, the licensed midwife must meet the EPA criteria listed
below.
How do I create an EPA number? Once the EPA criteria are met,
you must create a 9-digit EPA number. The first six digits of the
EPA number will be 870000. The last three digits must be 690, which
meets the EPA criteria listed below.
Note: This EPA number is ONLY for the procedure codes listed in
the fee schedule as “Not billable by a Licensed Midwife.”
Note: See the agency’s ProviderOne Billing and Resource Guide
for more information on requesting authorization.
EPA criteria for drugs not billable by licensed midwives To use
an EPA to bill procedure codes 90371, J2540, S0077, J0290, J1364,
the licensed midwife must meet all of the following: • Obtained
physician or standing orders for the administration of the drug
listed as not
billable by a licensed midwife.
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• Placed the physician or standing orders in the client’s
file.
• Will provide a copy of the physician or standing orders to the
agency upon request.
Note: Enter the EPA number (870000690) in the Prior
Authorization section of the electronic professional claim. Do not
handwrite the EPA number on the claim.
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Coverage Table Due to its licensing agreement with the American
Medical Association, the agency publishes only the official, short
CPT® code descriptions. To view the entire description, see your
current CPT book. Use the following CPT codes when billing for
Birthing Center services: Routine Prenatal Care
CPT Code Modifier Short Description Comments
59425 Antepartum care, 4-6 visits. Limited to 1 unit per client,
per pregnancy, per provider.
59426 Antepartum care, 7 or more visits.
Limited to 1 unit per client, per pregnancy, per provider.
99211 TH Office visits, Antepartum care 1-3 visits,
w/obstetrical service modifier.
99211 – 99215 limited to 3 units total, per pregnancy, per
provider. Must use modifier TH when billing.
99212 TH Office/outpatient visit, est
99213 TH Office/outpatient visit, est
99214 TH Office/outpatient visit, est
99215 TH Office/outpatient visit, est
Note: CPT codes 59425, 59426, or E&M codes 99211-99215 with
normal pregnancy diagnoses may not be billed in combination during
the entire pregnancy. Do not bill the agency for prenatal care
until all routine prenatal services are complete.
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Additional monitoring
CPT Code Modifier Short Description Comments
99211 TH Office/outpatient visit, est
99212 TH Office/outpatient visit, est
99213 TH Office/outpatient visit, est
99214 TH Office/outpatient visit, est
99215 TH Office/outpatient visit, est
Note: Midwives who provide increased monitoring for routine
prenatal care may bill using the appropriate E&M code with
modifier TH.
Delivery (intrapartum)
CPT Code Modifier Short Description Comments
59400
Obstetrical care (antepartum, delivery, and postpartum care)
59409 Obstetrical care (delivery only)
59410 Obstetrical care (delivery and postpartum only)
Postpartum
HCPCS Code Modifier Short Description Comments
59430 Care after delivery (postpartum only)
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Labor management Bill these codes only when the client labors at
the birthing center or at home and is then transferred to a
hospital, another provider delivers the baby, and a referral is
made during active labor. The diagnoses must be related to
complications during labor and delivery. The delivering physician
may not bill for labor management. Prolonged services must be
billed on the same claim as E&M codes along with modifier TH
and one of the diagnoses listed above (all must be on each detail
line of the claim).
CPT Code Modifier Short Description Comments
Use when client labors at birthing center
99211 TH Office/outpatient visit, est (Use when client labors at
birthing center)
99212 TH Office/outpatient visit, est
99213 TH Office/outpatient visit, est
99214 TH Office/outpatient visit, est
99215 TH Office/outpatient visit, est
Use when client labors at home
99347 TH Home visit, est patient
99348 TH Home visit, est patient
99349 TH Home visit, est patient
99350 TH Home visit, est patient
And
+ 99354 (Add-on
code)
TH Prolonged services, 1st hour. Limited to 1 unit.
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+ 99355 (Add-on
code)
TH Prolonged services, each add’l 30 minutes. Limited to 4
units.
Other Codes
CPT Code Modifier Short Description Comments
59020 Fetal contract stress test
59020 TC Fetal contract stress test
59020 26 Fetal contract stress test
59025 Fetal non-stress test
59025 TC Fetal non-stress test
59025 26 Fetal non-stress test
36415 Drawing blood
84703 Chorionic gonadotropin assay
85013 Hematocrit
85014 Hematocrit
A4266 Diaphragm
A4261 Cervical cap for contraceptive use
57170 Fitting of diaphragm/cap
90371 Hep b ig, im
Not billable by a licensed midwife. For exception, see
Authorization - Expedited Prior Authorization.
96372 Ther/Proph/Diag Inj, SC/IM
J2790 Rh immune globulin
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J2540 Injection, penicillin G potassium, up to 600,000
units.
Not billable by a Licensed Midwife. For exception, see
Authorization- Expedited Prior Authorization.
S0077 Injection, clindamycin phosphate, 300 mg.
Not billable by a Licensed Midwife. For exception, see
Authorization- Expedited Prior Authorization.
J0290 Injection, ampicillin, sodium, up to 500mg. (use separate
line for each 500 mg used)
Not billable by a Licensed Midwife. For exception, see
Authorization- Expedited Prior Authorization.
J1364 Injection, erythromycin lactobionate, per 500 mg. (use
separate line for each 500 mg used)
Not billable by a Licensed Midwife. For exception, see
Authorization- Expedited Prior Authorization.
J7050 Infusion, normal saline solution, 250cc
S5011 5% dextrose in lactated ringer, 1000 ml.
J7120 Ringers lactate infusion, up to 1000cc
96360 Hydration IV Infusion, Init
96361 Hydrate IV Infusion, add On
96365 Ther/proph/Diag IV Inf, Init
96366 Ther/proph/Diag IV Inf add on
J8499 Oral methergine 0.2 mg
Enter NDC on claim, see ProviderOne Billing and Resource Guide
for additional information
J2210 Injection methylergonovine maleate, up to 0.2mg
J3475 Injection, magnesium sulfate, per 500 mg
J2590 Injection, oxytocin
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J0170 Injection adrenalin, epinephrine, up to 1ml ampule
J3430 Injection, phytonadione (Vitamin K) per 1 mg.
90471 Immunization admin
90472 Immunization admin, each add
List separately in addition to code for primary procedure.
S3620 Newborn metabolic screening panel, include test kit,
postage and the laboratory tests specified by the state for
inclusion in this panel.
Department of Health (DOH) newborn screening tests for metabolic
disorders. Includes 2 tests on separate dates, one per newborn. DOH
will bill the agency for this service.
92588 Newborn hearing screen
99460 Init NB EM per day, Hosp Newborn assessment for a baby
born in a birthing center that is admitted and discharged on the
same day. Limited to one per newborn. Do not bill the agency if
baby is born in a hospital.
99461 Init NB EM per day, Non-Fac
Newborn assessment for a home birth. Limited to (1) one per
newborn.
99463 Same day NB discharge Newborn assessment for a baby born
in a birthing center who is transferred to a hospital for care.
99465 NB Resuscitation
92950 Cardiopulmonary resuscitation (e.g., in cardiac
arrest)
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Facility Fee Payment The agency reimburses for a facility fee
only when services are performed in birthing centers licensed by
the Department of Health and have a Core Provider Agreement with
the agency. The facility payments listed below will be billed by
and paid to the midwife who must then reimburse the birthing
center.
CPT Code Modifier Short Description Comments
59409 59 and SU Delivery only code with use of provider’s
facility or equipment modifier.
Limited to one unit per client, per pregnancy. Facility fee
includes all room charges, equipment, supplies, anesthesia
administration, and pain medication.
S4005 Interim labor facility global (labor occurring but not
resulting in delivery).
Limited to one per client, per pregnancy. May only be billed
when client labors in the birthing center and then transfers to a
hospital for delivery.
Note: Payments for facility use are limited to only those
providers who have been approved by the agency. When modifier SU is
attached to the delivery code, it is used to report the use of the
provider’s facility or equipment only.
Home Birth Kit
HCPCS Code Modifier Short Description Comments
S8415 Disposable supplies for home delivery of infant Limited to
one per client, per pregnancy.
What fees do I bill the agency? See the agency’s Planned Home
Births and Births in Birthing Centers Fee Schedule.
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What does global (total) obstetrical care include? Global
obstetrical (OB) care (CPT code 59400) includes: • Routine prenatal
care in any trimester • Delivery • Postpartum care If you provide
all of the client’s prenatal care, perform the delivery, and
provide the postpartum care, you must bill using the global OB
procedure code.
Note: Bill the global obstetric procedure code if you performed
all of the services and no other provider is billing for prenatal
care, the delivery, or postpartum care. (See WAC 182-533-0400(5).
If you provide all or part of the prenatal care and/or postpartum
care but you do not perform the delivery, you must bill the agency
for only those services provided using the appropriate prenatal
and/or postpartum codes. In addition, if the client obtains other
medical coverage or is transferred to an agency-contracted managed
care organization (MCO) during pregnancy, you must bill for only
those services provided while the client is enrolled with agency
fee-for-service.
What does routine prenatal care include? Prenatal care includes:
• Initial and subsequent history • Physical examination • Recording
of weight and blood pressure • Recording of fetal heart tones •
Routine chemical urinalysis • Maternity counseling, such as risk
factor assessment and referrals Necessary prenatal laboratory tests
may be billed in addition to prenatal care, except for dipstick
tests (CPT codes 81000, 81002, 81003, and 81007). In accordance
with CPT guidelines, the agency considers routine prenatal care for
a normal, uncomplicated pregnancy to consist of: • Monthly visits
up to 28 weeks gestation • Biweekly visits to 36 weeks gestation •
Weekly visits until delivery (approximately 14 prenatal visits)
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CPT Code Modifier Short Description Comments
59426 Prenatal care, 7 or more visits
Limited to one unit per client, per pregnancy.
59425 Prenatal care, 4-6 visits Limited to one unit per client,
per provider per pregnancy.
99211-99215
TH Office visits, prenatal care 1-3 visits only, w/obstetrical
service modifier
Note: Do not bill using CPT codes 59425, 59426, and E&M
codes 99211-99215 with normal pregnancy diagnoses in combination
with each other during the same pregnancy. Do not bill the agency
for prenatal care until all prenatal services are complete.
When an eligible client receives services from more than one
provider, the agency reimburses each provider for the services
furnished (WAC 182-533-0400(7))
Example: For a client being seen by both a midwife and a
physician, the agency’s reimbursement for the co-management of the
client would be as follows:
• The physician would be paid for the consult office visits. •
The midwife would be paid for the prenatal visits.
Is obstetrical care allowed to be unbundled? In the situations
described below, you may not be able to bill the agency for global
OB care. In these cases, it may be necessary to unbundle the OB
services and bill the prenatal, delivery, and postpartum care
separately, as the agency may have paid another provider for some
of the client’s OB care, or another insurance carrier may have paid
for some of the client’s OB care.
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When a client transfers to your practice late in the pregnancy •
Do not bill the global OB package. Bill the prenatal care,
delivery, and postpartum care
separately if the client has had prenatal care elsewhere. The
provider who had been providing the prenatal care prior to the
transfer bills for the services performed. Therefore, if you bill
the global OB package, you would be billing for some prenatal care
that another provider has claimed.
• If the client did not receive any prenatal care prior to
coming to your office, bill the global
OB package. In this case, you may actually perform all of the
components of the global OB package in a short time. The agency
does not require you to perform a specific number of prenatal
visits in order to bill for the global OB package.
If the client moves to another provider (not associated with
your practice), moves out of your area prior to delivery, or loses
the pregnancy Bill only those services you actually provide to the
client. If the client changes insurance during pregnancy When a
client changes from one agency-contracted MCO to another, bill
those services that were provided while the client was enrolled
with the original MCO to the original carrier, and those services
that were provided under the new coverage to the new MCO. You must
unbundle the services and bill the prenatal, delivery, and
postpartum care separately. Often, a client will be eligible for
fee-for-service at the beginning of pregnancy, and then be enrolled
in an agency-contracted MCO for the remainder of pregnancy. The
agency is responsible for reimbursing only those services provided
to the client while the client is on fee-for-service. The MCO
reimburses for services provided after the client is enrolled with
the MCO.
Coding for prenatal care only If it is necessary to unbundle the
global package and bill separately for prenatal care, bill one of
the following: • If the client had a total of one to three prenatal
visits, bill the appropriate level of E&M
service with modifier TH for each visit with the date of service
the visit occurred and the appropriate diagnosis.
Modifier TH: Obstetrical treatment/service, prenatal or
postpartum
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• If the client had a total of four to six prenatal visits, bill
using CPT code 59425 with a one
(1) in the units box. Bill the agency using the date of the last
prenatal visit in the to and from fields.
• If the client had a total of seven or more visits, bill using
CPT code 59426 with a one (1)
in the units box. Bill the agency using the date of the last
prenatal visit in the to and from fields fo the form.
Do not bill prenatal care only codes in addition to any other
procedure codes that include prenatal care (i.e. global OB codes).
When billing for prenatal care, do not bill using CPT E/M codes for
the first three visits, then CPT code 59425 for visits four through
six, and then CPT code 59426 for visits seven and on. These CPT
codes are used to bill only the total number of times you saw the
client for all prenatal care during pregnancy, and may not be
billed in combination with each other during the entire pregnancy
period.
Note: Do not bill the agency until all prenatal services are
complete.
Coding for deliveries If it is necessary to unbundle the OB
package and bill for the delivery only, bill the agency using one
of the following CPT codes: • 59409 (vaginal delivery only) • 59514
(cesarean delivery only) • 59612 [vaginal delivery only, after
previous cesarean delivery (VBAC)] • 59620 [cesarean delivery only,
after attempted vaginal delivery after previous cesarean
delivery (attempted VBAC)] If a provider does not furnish
prenatal care, but performs the delivery and provides postpartum
care, bill the agency one of the following CPT codes: • 59410
(vaginal delivery, including postpartum care) • 59515 (cesarean
delivery, including postpartum care) • 59614 (VBAC, including
postpartum care) • 59622 (attempted VBAC, including postpartum
care)
Natural Deliveries For all natural deliveries for a client equal
to or over 39 weeks gestation, bill using EPA #870001378. For a
natural delivery before 39 weeks, use EPA #870001375.
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CPTCode Short Description EPA Number
CPT: 59400, 59409, 59410
Elective delivery or natural delivery at or over 39 weeks
gestation
870001378
CPT: 59400, 59409, 59410
Natural delivery before 39 weeks 870001375
Coding for postpartum care only If it is necessary to unbundle
the global OB package and bill for postpartum care only, you must
bill the agency using CPT code 59430 (postpartum care only). If you
provide all of the prenatal and postpartum care, but do not perform
the delivery, bill the agency for the prenatal care using the
appropriate coding for prenatal care (see Authorization), along
with CPT code 59430 (postpartum care only). Do not bill CPT code
59430 (postpartum care only) in addition to any procedure codes
that include postpartum care.
Note: Postpartum care includes office visits for the six-week
period after the delivery and includes family planning
counseling.
Additional monitoring for high-risk conditions When providing
increased monitoring for the conditions listed below in excess of
the CPT guidelines for normal prenatal visits, bill using E&M
codes 99211-99215 with modifier TH. The office visits may be billed
in addition to the global fee only after exceeding the CPT
guidelines for normal prenatal care (i.e., monthly visits up to 28
weeks gestation, biweekly visits to 36 weeks gestation, and weekly
visits until delivery).
CPT Code Modifier Short Description Comments
99211-99215 TH Office visits; use for increased monitoring
prenatal management for high-risk conditions.
See the Prenatal Management/Consultation and Referral
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If the client has one of the conditions listed above, the
provider is not automatically entitled to additional payment. In
accordance with CPT guidelines, it must be medically necessary to
see the client more often than what is considered routine prenatal
care in order to qualify for additional payments. The additional
payments are intended to cover additional costs incurred by the
provider as a result of more frequent visits.
Note: Licensed midwives are limited to billing for certain
medical conditions (see Prenatal Management/Consultation and
Referral) that require additional monitoring under this
program.
For example:
Client A is scheduled to see the client’s provider for prenatal
visits on January 4, February 5, March 3, and April 7. The client
attends the January and February visits as scheduled. However,
during the scheduled February visit, the provider discovers the
client’s blood pressure is slightly high and wants the client to
come in on February 12 to be checked again. At the February 12
visit, the provider discovers the client’s blood pressure is still
slightly high and asks to see the client again on February 18. The
February 12 and February 18 visits are outside of the client’s
regularly scheduled prenatal visits, and outside of the CPT
guidelines for routine prenatal care since the client is being seen
more often than once per month. The February 12 and February 18
visits may be billed separately from the global prenatal visits
using the appropriate E&M codes with modifier TH, and the
diagnosis must represent the medical necessity for billing
additional visits. A normal pregnancy diagnosis will be denied
outside of the global prenatal care. It is not necessary to wait
until all services included in the routine prenatal care are
performed to bill the extra visits, as long as the extra visits are
outside of the regularly scheduled visits.
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Labor management Providers may bill for labor management only
when another provider (outside of your group practice) performs the
delivery. If you performed the entire prenatal care for the client,
attended the client during labor, delivered the baby, and performed
the postpartum care, do not bill the agency for labor management.
These services are included in the global OB package. However, if
you performed all of the client’s prenatal care and attended the
client during labor, but transferred the client to another provider
(outside of your group practice) for delivery, you must unbundle
the global OB package and bill separately for prenatal care and the
time spent managing the client’s labor. The client must be in
active labor when the referral to the delivering provider is made.
To bill for labor management in the situation described above, bill
the agency for the time spent attending the client’s labor using
the appropriate CPT E&M codes 99211-99215 (for labor attended
in the office) or 99347-99350 (for labor attended at the client’s
home). In addition, the agency will reimburse providers for up to
three hours of labor management using prolonged services CPT codes
99354-99355 with modifier TH. Reimbursement for prolonged services
is limited to three hours per client, per pregnancy, regardless of
the number of calendar days a client is in labor, or the number of
providers who provide labor management. Labor management may not be
billed by the delivering provider, or by any provider within the
delivering provider’s group practice.
Note: The E&M code and the prolonged services code must be
billed on the same claim.
CPT Code Modifier Short Description Comments
99211–99215 TH Office visits – labor at birthing center
99347-99350 TH Home visits – labor at home
+99354
TH Prolonged services, First hour
Limited to one unit
+99355
TH Prolonged services, each add’l 30 minutes
Limited to four units
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Does the agency pay for newborn screening tests? The midwife or
physicians will collect the blood for the newborn screening and
send it to DOH. DOH will bill the agency for payment of HCPCS code
S3620. The newborn screening panel includes: • Biotinidase
deficiency • Congenital adrenal hyperplasia (CAH) • Congenital
hypothyroidism • Homocystinuria • Phenylketonuria (PKU) •
Galactosemisa • Hemoglobinopathies • Homocystinuria • Maple Syrup
Urine Disease (MSUD) • Medium chain acyl-CoA dehydrogenase
deficiency (MCAD deficiency) • Severe combined immunodeficiency
(SCID)
Note: Payment includes two tests for two different dates of
service, allowed once per newborn. Do not bill HCPCS code S3620 if
the baby is born in the hospital. This code is only for outpatient
services in birthing centers, physician offices, and homes in which
midwives provide home births.
How is the administration of immunizations billed? Immunization
administration CPT codes 90471 and 90472 may be billed only when
the materials are not received free of charge from DOH. For
information on Immunizations, see the agency’s Physician-Related
Services/Healthcare Professional Services Billing Guide or Early
Periodic Screening, Diagnosis & Treatment (EPSDT) Billing
Guide.
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How are home-birth supplies billed? Home-birth supplies are
billed using HCPCS code S8415. Payment is limited to one per
client, per pregnancy.
HCPCS Code Description Limits
S8415 Supplies for home delivery of infant
Limited to one per client, per pregnancy.
Are medications billed separately? Certain medications can be
billed separately and are listed on the fee schedule. Some of the
medications listed in the agency’s fee schedule are not billable by
licensed midwives. By law, a licensed midwife may obtain and
administer only certain medications. Drugs listed as not billable
by a licensed midwife must be obtained at a pharmacy with a
physician’s order. (See EPA criteria for drugs not billable by
Licensed Midwives).
Long Acting Reversible Contraception (LARC) For information
regarding family planning services including long acting reversible
contraceptives (LARC), see the Family Planning Billing Guide.
Note: Drugs must be billed using the procedure codes listed in
the fee schedule and they are reimbursed at the agency’s
established maximum allowable fees. Name, strength, and dosage of
the drug must be documented and retained in the client’s file for
review at the agency’s request.
How are newborn assessments billed? Home birth setting To bill
for a newborn assessment completed at the time of the home birth,
providers must bill using CPT code 99461. Reimbursement is limited
to one per newborn. Do not bill CPT code 99461 if the baby is born
in a hospital. Bill on a separate claim . On the claim , answer
“Yes” to
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the question,“Is the claim for a Baby on Mom’s Client ID?” And
enter SCI=B in the Claim Note section of the claim. Birthing center
births To bill for a newborn assessment completed at the time of a
birthing center birth for a baby that is admitted and discharged on
the same day, use CPT code 99460. For a baby that is born in a
birthing center, when a newborn assessment is completed and the
baby is transferred to a hospital for care, bill with CPT code
99463.
How is the facility fee billed in birthing centers?
Note: The midwife may bill the agency for the facility fee or
facility transfer fee payment. The agency pays the midwife, who
then reimburses the approved birthing center. See Resources
Available for a list of approved birthing centers.
Facility Fee – When billing for the facility fee, use CPT code
59409 with modifiers SU and 59. Only a facility licensed as a
childbirth center by DOH and approved by the agency is eligible for
a facility fee. Bill this fee only when the baby is born in the
facility. The facility fee includes all room charges for client and
baby, equipment, supplies, anesthesia administration, and pain
medication. The facility fee does not include other drugs,
professional services, newborn hearing screens, lab charges,
ultrasounds, other x-rays, blood draws, or injections. Facility
Transfer Fee – The facility transfer fee may be billed when the
mother is transferred in active labor to a hospital for delivery
there. Use CPT code S4005 when billing for the facility transfer
fee.
Procedure Code Modifier Description Limits
59409 59 SU
Delivery only code with use of provider’s facility or equipment
modifier.
Limited to one per client, per pregnancy.
S4005 Interim labor facility global (labor occurring but not
resulting in delivery)
Limited to one per client, per pregnancy may only be billed when
client labors in the birthing center and then transfers to a
hospital for delivery.
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Note: Payments to midwives for facility use are limited to only
those birthing centers that have been approved by the agency. When
modifier SU is attached to the delivery code, it is used to report
the use of the provider’s facility or equipment only. The name of
the birthing center must be entered in entered in the Service
Facility section under the Other Claim Info tab.
What additional documentation must be kept in the client’s
record? WAC 182-533-0600 Prenatal care records • Initial general
(Gen) history, physical examination, and prenatal lab tests •
Gynecological (Gyn) history, including obstetrical history,
physical examination, and
standard lab tests. Ultrasound, if indicated • Subsequent
Gen/Gyn history, physical and lab tests • Client’s weight, blood
pressure, fetal heart tones, fundal height, and fetal position
at
appropriate gestational age • Consultation, referrals, and
reason for transferring care, if necessary • Health education and
counseling • Consultation or actual evaluation by the consulting
physician for any high-risk condition • Risk screening evaluation
Intrapartum/postpartum care records • Labor, delivery, and
postpartum periods • Maternal, fetal, and newborn well-being,
including monitoring of vital signs, procedures,
and lab tests • Any consultation referrals and reason for
transferring care, if necessary • Initial pediatric care for
newborn, including the name of the pediatric care provider, if
known • Postpartum follow-up, including family planning
Informed consent materials • Copy of informed consent, including
all of the following:
Scope of maternal and infant care Description of services
provided, including newborn screening, prophylaxis eye
treatment, and screening for genetic heart defects
http://apps.leg.wa.gov/WAC/default.aspx?cite=182-533-0600
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Parents may refuse – documentation must include a signed waiver
for each service that is declined
Limitations of technology and equipment in the home birth
setting Authority to treat Plan for physician consultation or
referral Emergency plan Informed assumption of risks Client
responsibilities and requirements
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Billing
Effective for claims billed on and after October 1, 2016 All
claims must be submitted electronically to the agency, except under
limited circumstances.
For more information about this policy change, see Paperless
Billing at HCA. For providers approved to bill paper claims, see
the agency’s Paper Claim Billing Resource.
What are the general billing requirements? Providers must follow
the agency’s ProviderOne Billing and Resource Guide. These billing
requirements include: • What time limits exist for submitting and
resubmitting claims and adjustments • When providers may bill a
client • How to